aqi qcdr measure specificationapr 27, 2015 · the american society of anesthesiologists (asa), and...

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AQI QCDR

Measure

Specification Year 2015

Anesthesia Quality Institute Updated 4/27/15

©2015 Anesthesia Quality Institute. All rights reserved. Please contact Ashley Kieta for permission to use any of the information in this document. Page 1

Contents

ASA #6: Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from

Procedure Room to Intensive Care Unit (ICU)* ......................................................................................................3

ASA #7: Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy (Adults)* .............6

ASA #8: Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)*..............................9

ASA #9: Anesthesiology: Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia

Care Unit .............................................................................................................................................................. 12

ASA #10: Composite Anesthesia Safety .............................................................................................................. 15

ASA #11: Immediate Perioperative Cardiac Arrest ............................................................................................. 18

ASA #12: Immediate Perioperative Mortality Rate ............................................................................................ 20

ASA #13: Post Anesthesia Care Unit (PACU) Re-intubation Rate ........................................................................ 22

ASA #14: Short-term Pain Management ............................................................................................................ 24

ASA #15: Composite Procedural Safety for Central Line Placement .................................................................. 26

ASA #16: Composite Patient Experience ............................................................................................................. 28

ASA #17: Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics (NQF 269)* ........ 31

ASA #18: Perioperative Temperature Management* ........................................................................................ 35

ASA #19: Perioperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents* .................................. 38

ASA #20: Surgical Safety Checklist – Applicable Safety Checks Completed Before Induction of Anesthesia* .. 41

ASA #21: Smoking Abstinence ............................................................................................................................ 44

ASA #22: Corneal Injury Diagnosed in the Post-Anesthesia Care Unit/Recovery Area after Anesthesia Care . 46

ASA #23: Coronary Artery Bypass Graft (CABG): Prolonged Intubation............................................................. 48

ASA #24: Coronary Artery Bypass Graft (CABG): Stroke ..................................................................................... 50

ASA #25: Coronary Artery Bypass Graft (CABG): Post-Operative Renal Failure ................................................. 52

ASA #28: Rate of Post-operative stroke or death in asymptomatic patients undergoing Carotid Artery Stenting

(CAS) .................................................................................................................................................................... 54

ASA #29: Rate of Post-operative stroke or death in asymptomatic patients undergoing Carotid Artery

Endarterectomy (CAE) ......................................................................................................................................... 56

ASA #30: Rate of Endovascular aneurysm repair (EVAR) of small or moderate non-ruptured abdominal aortic

aneurysms (AAA) who expire while in the hospital ............................................................................................ 58

ASA #31: Total Knee Replacement: Venous thromboembolic and Cardiovascular Risk Evaluation ................... 60

ASA #32: Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet....................... 63

ASA #33: Unplanned Hospital Readmission within 30 days of Principal Procedure ........................................... 65

ASA #34: Surgical Site Infection ........................................................................................................................... 69

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These performance measures (Measures) are not clinical guidelines, do not establish a standard of medical

care, and have not been tested for all potential applicants. The American Society of Anesthesiologists (ASA),

and its related organization, the Anesthesia Quality Institute (AQI), shall not be responsible for any use of the

Measures.

The Measures, while copyrighted, can be reproduced and distributed, without modification, for non-

commercial purposes, e.g., use by health care providers in connection with their practices.

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ASA and AQI encourage use of the Measures by other health care professionals, where appropriate. Please

contact Ashley Kieta before using information contained in this document to ensure proper permissions are

obtained.

Limited proprietary coding is contained in the Measure specifications for convenience. Users of the

proprietary code sets should obtain all necessary licenses from the owners of these code sets. ASA and AQI

disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding

contained in the specifications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.

* The following notice (in addition to the notice above) applies to each of the Measures that contains an

asterisk (*) within its title.

Commercial uses of the Measures require a license agreement between the user and the American Medical

Association (AMA), [on behalf of the Physician Consortium for Performance Improvement® (PCPI®)] or ASA.

Neither the AMA, ASA, PCPI, or its members shall be responsible for any use of the Measures.

The AMA’s, PCPI’s and National Committee for Quality Assurance’s significant past efforts and contributions

to the development and updating of the Measures is acknowledged. ASA is solely responsible for the review

and enhancement (“Maintenance”) of the Measures as of May 2014.

Limited proprietary coding is contained in the Measure specifications for convenience. Users of the

proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, ASA,

the PCPI and its members disclaim all liability for use or accuracy of any Current Procedural Terminology

(CPT®) or other coding contained in the specifications.

CPT® contained in the Measures specifications is copyright 2004-2013 American Medical Association. LOINC®

copyright 2004-2013 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004-2013

College of American Pathologists. All Rights Reserved.

© 2015 American Medical Association and American Society of Anesthesiologists. All Rights Reserved.

Applicable FARS/DFARS Restrictions Apply to Government Use.



Measure Title

*ASA #6: Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct

Transfer of Care from Procedure Room to Intensive Care Unit (ICU)

Measure Description

Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an

Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or

protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team

member

NQS Domain

Communication and Care Coordination

Measure Type (Process/Outcome)

Process

Instructions:

This measure is to be reported each time a patient who undergoes a procedure under anesthesia is transferred from

an anesthetizing location to the Intensive Care Unit (ICU).

Measure Reporting via the Qualified Clinical Data Registry

CPT codes and patient demographics are used to identify patients who are included in the measure's denominator.

CPT Category II codes are used to report the numerator of the measure.

When reporting via claims, submit the listed CPT codes, and the appropriate CPT Category II code or the

appropriate CPT Category II code with the modifier. The modifiers allowed for this measure are: 1P - medical

reasons, 8P - reason not otherwise specified. All measure-specific coding should be reported on the claims

representing the eligible encounter as the denominator codes.

Denominator

All patients, regardless of age, who receive an anesthetic and are admitted to an ICU directly from the

anesthetizing location,

Denominator Criteria (Eligible Cases):

Patient of any age

AND

CPT II 0581F: Patient transferred directly from anesthetizing location to critical care unit

AND

Patient encounter during the reporting period (CPT):

00100, 00102, 00103, 00104, 00120, 00124, 00120, 00124, 00126, 00140, 00142, 00144, 00145,

00147, 00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211,

00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352,

00400, 00402, 00404, 00406, 00410, 00450, 00452, 00454, 00470, 00472, 00474, 00500, 00520,

00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546,

00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600, 00604, 00620, 00622,

00625, 00626, 00630, 00632, 00634, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750,



00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820,

00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864,

00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910,

00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934,

00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150,

01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230,

01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390,

01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470,

01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620,

01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710,

01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772,

01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860,

01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951,

01952, 01958, 01960, 01961, 01962, 01963, 01965, 01966, 01968, 01969, 01991, 01992

Denominator Exclusions / Exceptions

None

Numerator

Patients who have a documented use of a checklist or protocol for the transfer of care from the responsible

anesthesia practitioner to the responsible ICU team or team member

Definition:

The key handoff elements that must be included in the transfer of care protocol or checklist include:

1. Identification of patient, key family member(s) or patient surrogate

2. Identification of responsible practitioner (primary service)

3. Discussion of pertinent medical history

4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed)

5. Intraoperative anesthetic management and issue/concerns to include things such as airway,

hemodynamic, narcotic, sedation level and paralytic management and intravenous fluids/blood

products and urine output during the procedure

6. Expectations/Plans for the early post-procedure period to include things such as the anticipated

course (anticipatory guidance), complications, need for laboratory or ECG and medication

administration

7. Opportunity for questions and acknowledgement of understanding of report from the receiving

ICU team

Numerator Quality-Data Coding Options for Reporting Satisfactorily

Performance Met:

CPT II 0583F Transfer of care checklist used

OR

Transfer of Care Not Documented – Medical Performance Exclusion:

CPT II 0583F-1P Documentation of medical reason that transfer

of care checklist not used

OR

Transfer of Care Not Documented – Reason Unspecified:

CPT II 0583F-8P Transfer of care checklist not used, reason not

given



Rationale

A uniform transfer of care protocol or handoff tool/checklist that is utilized for all patients directly admitted to the

ICU after undergoing a procedure under the care of an anesthesia practitioner will facilitate effective

communications between the medical practitioner who provided anesthesia during the procedure and the care

practitioner in the ICU who is responsible for post-procedural care. This should minimize errors and oversights in

medical care of ICU patients after procedures.

According to data published by the Joint Commission, communication errors were indicated in 59% of reported

sentinel events in 2012 and in 54% of operative/post-operative complications between 2004 and 2012. A 2006

survey among residents at Massachusetts General Hospital found that 59% of respondents reported one or more

patients experiencing harm as a result of ineffective patient handoff practices during their most recent clinical

rotation.

Clinical Recommendation Statements:

The National Quality Forum, in its Preferred Practices and Performance Measures for Measuring and Reporting

Care Coordination report, recommends:

Preferred Practice 23: Healthcare providers and healthcare organizations should implement protocols and policies

for a standardized approach to all transitions of care. Policies and procedures related to transitions and the critical

aspects should be included in the standardized approach.

Measure Steward

American Society of Anesthesiologists (ASA) / Anesthesia Quality Institute (AQI)



Measure Title

*ASA #7: Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination

Therapy (Adults)

Measure Description

Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general

anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who

receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different

classes preoperatively or intraoperatively.

NQS Domain

Person and Caregiver-Centered Experience and Outcomes


Process

Instructions:

This measure is to be reported each time a patient having risk factors for PONV is treated pre-operatively or intra-

operatively following inhalation general anesthetic.








Denominator

All patients, aged 18 years and older, who undergo a procedure* under an inhalational general anesthetic, AND

who have three or more risk factors for PONV


Patients aged 18 years and older

AND

CPT II 4554F: Patient received inhalation anesthetic agent

AND

CPT II 4556F: Patient has three or more risk factors for post-operative nausea and vomiting

(PONV)

Risk factors for PONV include:

1. Female gender

2. History of PONV or a history of motion sickness

3. Non-smoker

4. Intended administration of opioids for post-operative analgesia**

* Any procedure including surgical, therapeutic or diagnostic.



** This includes use of opioids given intra-operatively and whose effects extend into the post

anesthesia care unit (PACU) or post-operative period, or opioids given in the PACU, or opioids given

after discharge from the PACU.

AND

CPT® Code for Procedure:

00100, 00102, 00103, 00104, 00120, 00124, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147,

00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214,

00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404,

00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530,

00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563,

00566, 00567, 00580, 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700,

00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800,

00802, 00810, 00820, 00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860,

00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908,

00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934,

00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160,

01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234,

01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402,

01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482,

01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638,

01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740,

01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832,

01840, 01842, 01844, 01850, 01852, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931,

01932, 01933, 01935, 01936, 01951, 01952, 01958, 01960, 01961, 01962, 01963, 01965, 01966, 01968,

01969, 01991, 01992


Patient has less than three risk factors for post-operative nausea and vomiting (PONV)

Numerator

Patients who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic

agents of different classes preoperatively or intraoperatively

Definition: The recommended first- and second-line classes of pharmacologic anti-emetics for PONV

prophylaxis in patients at moderate to severe risk of PONV include (but are not limited to):

5-hydroxytryptamine (5-HT3) receptor antagonists (e.g., ondansetron, dolasetron, granisetron and

tropisetron)

steroids (e.g., dexamethasone)

phenothiazines (e.g., promethazine, prochlorperazine)

phenylethylamine (e.g., ephedrine)

butyrophenones (e.g., droperidol, haloperidol)

antihistamine (e.g., dimenhydrinate, diphenhydramine)

anticholinergic (e.g., transdermal scopolamine)



The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The

specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list

of selected drugs may not be current. Physicians and other health care professionals should refer to the

FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert

information when prescribing medications.


Performance Met:

4558F Patient received at least 2 prophylactic pharmacologic anti-emetic agents

of different classes preoperatively and intra-operatively

OR

Performance Not Met – Medical Performance Exclusion: 4558F-1P Documentation of medical reason(s) for not administering combination therapy

of at least two prophylactic pharmacologic anti-emetic agents of different classes

(eg, intolerance or other medical reason)

OR

Performance Not Met – Reason Unspecified: 4558F-8P Combination therapy of at least two prophylactic pharmacologic anti-

emetic agents of different classes not administered, reason unspecified

Rationale

Postoperative nausea and vomiting (PONV) is an important patient-centered outcome of anesthesia care. PONV

is highly dis-satisfying to patients, although rarely life-threatening. A large body of scientific literature has

defined risk factors for PONV; demonstrated effective prophylactic regimes based on these risk factors, and

demonstrated high variability in this outcome across individual centers and providers. Further, a number of

papers have shown that performance can be assessed at the level of individual providers -- the outcome is

common enough that sufficient power exists to assess variability and improvement at this level.


The following evidence statements are quoted verbatim from the referenced clinical guidelines:

Society for Ambulatory Anesthesia (SAMBA) PONV Prophylaxis Recommendations:

Administer prophylactic therapy with combination ( ≥ 2 ) interventions/multimodal therapy in patients at high risk

for PONV

Measure Steward




Measure Title

*ASA #8: Prevention of Post-Operative Vomiting (POV) - Combination Therapy

(Pediatrics)

Measure Description

Percentage of patients aged 3 through 17 years of age, who undergo a procedure under general anesthesia in

which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-

operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic

pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively.

NQS Domain



Process

Instructions:

This measure is to be reported each time a patient having risk factors for POV is treated pre-operatively or intra-

operatively following inhalation general anesthetic.


CPT codes, patient demographics and registry codes are used to identify patients who are included in the

measure's denominator. CPT Category II codes are used to report the numerator of the measure.





Denominator

All patients, aged 3 through 17 years of age, who undergo a procedure under general anesthesia in which an

inhalational anesthetic is used for maintenance AND who have two or more risk factors for POV.

Definition: Risk factors for POV are:

Surgery ≥ 30 minutes

Age ≥ 3 years

Strabismus surgery

History of POV or PONV in parent or sibling


Patients Aged > 3 years old and < 17 years old

AND

ASA08A: Patient received general anesthetic with inhalational anesthetic for maintenance

AND

ASA08B: Patient has two or more risk factors for POV



AND

CPT® Code for Procedure:

00100, 00102, 00103, 00104, 00120, 00124, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147,

00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214,

00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404,

00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530,

00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563,

00566, 00567, 00580, 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700,

00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800,

00802, 00810, 00820, 00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860,

00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908,

00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934,

00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160,

01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234,

01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402,

01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482,

01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638,

01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740,

01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832,

01840, 01842, 01844, 01850, 01852, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931,

01932, 01933, 01935, 01936, 01951, 01952, 01958, 01960, 01961, 01962, 01963, 01965, 01966, 01968,

01969, 01991, 01992


Cases in which an inhalational anesthetic is used only for induction.

Numerator

Patients who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic

agents of different classes preoperatively or intraoperatively

Definition: The recommended pharmacologic anti-emetics for POV prophylaxis in pediatric patients at risk

of POV include (but may not be limited to):

5-hydroxytryptamine (5-HT3) receptor antagonists (recommended as the first choice for

prophylaxis for POV in children)

Dexamethasone

Antihistamines

Butyrophenones

The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The

specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list

of selected drugs may not be current. Physicians and other health care professionals should refer to the

FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert

information when prescribing medications.




Performance Met:

4558F Patient received at least 2 prophylactic pharmacologic anti-emetic agents

of different classes preoperatively and intra-operatively

OR

Performance Not Met – Medical Performance Exclusion: 4558F-1P Documentation of medical reason(s) for not administering combination therapy

of at least two prophylactic pharmacologic anti-emetic agents of different classes

(eg, intolerance or other medical reason)

OR

Performance Not Met – Reason Unspecified: 4558F-8P Combination therapy of at least two prophylactic pharmacologic

Anti-emetic agents of different classes not administered, reason unspecified

Rationale

Postoperative nausea and vomiting (PONV) is an important patient-centered outcome of anesthesia care. PONV

is highly dis-satisfying to patients, although rarely life-threatening. A large body of scientific literature has

defined risk factors for PONV; demonstrated effective prophylactic regimes based on these risk factors, and

demonstrated high variability in this outcome across individual centers and providers. Further, a number of

papers have shown that performance can be assessed at the level of individual providers -- the outcome is

common enough that sufficient power exists to assess variability and improvement at this level. A separate

measure is needed for pediatric patients because the risk factors and recommended prophylaxis are different from

adults.



Society for Ambulatory Anesthesia (SAMBA) recommendations:

Administer prophylactic antiemetic therapy to children at increased risk for POV; as in adults, use of combination

therapy is most effective.

All prophylaxis in children at moderate or high risk for POV should include combination therapy using a 5-HT3

antagonist and a second drug. Because the effects of interventions from different drug classes are additive,

combining interventions has an additive effect in risk reduction.

Measure Steward




Measure Title

ASA #9: Anesthesiology: Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit

Measure Description

Percentage of patients who are under the care of an anesthesia practitioner and are admitted to a PACU in which a

post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is

utilized.

NQS Domain

Communications and Care Coordination


Process

Instructions:

This measure is to be reported each time a care protocol or check list is utilized for patients admitted to a PACU.



CPT Category II codes and registry codes are used to report the numerator of the measure.





Denominator

All patients who are cared for by an anesthesia practitioner and are transferred directly from the procedure room

to the PACU upon completion of the anesthetic.

Note: This measure does not include transfer of care during an anesthetic or to the ICU.


Patient of any age

AND

ASA09A Patient transferred directly from anesthetizing location to PACU

AND

Patient encounter during the reporting period (CPT): Anesthesia codes which are commonly indicated for associated surgical procedure(s):

00100, 00102, 00103, 00104, 00120, 00124, 00120, 00124, 00126, 00140, 00142, 00144, 00145,

00147, 00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211,

00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352,

00400, 00402, 00404, 00406, 00410, 00450, 00452, 00454, 00470, 00472, 00474, 00500, 00520,

00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546,

00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600, 00604, 00620, 00622,



00625, 00626, 00630, 00632, 00634, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750,

00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820,

00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864,

00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910,

00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934,

00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150,

01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230,

01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390,

01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470,

01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620,

01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710,

01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772,

01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860,

01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951,

01952, 01958, 01960, 01961, 01962, 01963, 01965, 01966, 01968, 01969, 01991, 01992


All age patients who have been cared for by an anesthesia practitioner who is not admitted from the operating

room directly to a PACU.

Numerator

All patients who have been cared for by an anesthesia practitioner and are transferred directly from the procedure

room to post-anesthesia care unit (PACU) for whom a checklist or protocol which includes the key transfer of

care elements was utilized.

Definition:

The key handoff elements that must be included in the transition of care are:

1. Identification of patient

2. Identification of responsible practitioner (PACU nurse or advanced practitioner)

3. Discussion of pertinent medical history

4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed)

5. Intraoperative anesthetic management and issues/concerns.

6. Expectations/Plans for the early post-procedure period.

7. Opportunity for questions and acknowledgement of understanding of report from the receiving

PACU team


Performance Met:

CPT II 0583F: Transfer of care checklist used

OR

Transfer of Care Not Documented – Medical Performance Exclusion:

CPT II 0583F-1P: Documentation of medical reason that transfer of care

checklist not used

OR

Transfer of Care Not Documented – Reason Unspecified:

CPT II 0583F-8P Transfer of care checklist not used, reason not given



Rationale

Hand-offs are a vulnerable moment for patient safety, but required in any 24/7 healthcare system. Anesthesia

providers routinely transfer patients from the OR to the PACU, and are responsible for transmitting knowledge

about patient history, a summary of intra-operative events, and future plans for hemodynamic and pain

management to the new care team. Evidence demonstrates that this process can be facilitated by use of a checklist

that motivates completion of all key components of the transfer, and is seen as an emerging best practice in

anesthesia care.


The National Quality Forum, in its Preferred Practices and Performance Measures for Measuring and Reporting

Care Coordination report, recommends:

Preferred Practice 23: Healthcare providers and healthcare organizations should implement protocols and policies

for a standardized approach to all transitions of care. Policies and procedures related to transitions and the critical

aspects should be included in the standardized approach.

Measure Steward




Measure Title:

ASA #10: Composite Anesthesia Safety

Measure Description

Percentage of patients who underwent an anesthetic without the occurrence of a major adverse event.

NQS Domain

Effective Clinical Care


Outcome

Instructions:

This measure is to be reported each time a patient undergoes a surgical, therapeutic or diagnostic procedure under

anesthesia.



Registry codes are used to report the numerator of the measure.

Denominator

All patients, regardless of age, who undergo a procedure* under anesthesia

Definition: *Any procedure including surgical, therapeutic or diagnostic


Patient encounter during the reporting period (CPT): 00100, 00102, 00103, 00104, 00120, 00124,

00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172,

00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300,

00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472,

00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541,

00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600, 00604, 00620,

00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754,

00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, 00834,

00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870,

00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920,

00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948,

00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202,

01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320,

01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442,

01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520,

01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680,

01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770,

01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860,

01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952,

01958, 01960, 01961, 01962, 01963, 01965, 01966,, 01968, 01969, 01991, 01992




None

Numerator

Patients who experienced a major adverse event* prior to completion of anesthesia care**.

Definition: *Major adverse events of anesthesia are defined according to the 2009 Committee of

Performance and Outcomes Measurement work product “Development of the ASA Critical Incidents

Reporting System. The adverse events and their definitions can be accessed here:

http://www.aqihq.org/files/CPOM-registry-data-set.pdf. Adverse events include:

Death

Cardiac arrest

Perioperative myocardial infarction

Anaphylaxis

Malignant hyperthermia

Transfusion reaction

Stroke, cerebral vascular accident, or coma following anesthesia

Visual loss

Operation on incorrect site

Operation on incorrect patient

Medication error

Unplanned ICU admission

Intraoperative awareness

Unrecognized difficult airway

Reintubation

Dental trauma

Perioperative aspiration

Vascular access complication, including vascular injury or pneumothorax

Pneumothorax following attempted vascular access or regional anesthesia

Infection following epidural or spinal anesthesia

Epidural hematoma following spinal or epidural anesthesia

High Spinal

Postdural puncture headache

Major systemic local anesthetic toxicity

Peripheral neurologic deficit following regional anesthesia

Infection following peripheral nerve block

** Anesthesia care is completed when the patient is discharged from the Postanesthesia Care Unit

(PACU) or admitted to the Intensive Care Unit.


http://www.aqihq.org/files/CPOM-registry-data-set.pdf



Performance Met:

ASA10A: Patient did not experience an adverse event prior to completion of anesthesia

care.

OR

Performance Not Met:

ASA10B: Patient experienced an adverse event prior to completion of anesthesia care

Rationale

Serious adverse events are rare in anesthesia care, but can be assessed for performance improvement purposes as a

composite of mortality, major organ system injury, and unintended events (e.g. anaphylaxis, cardiac arrest) that

carry a high risk. Completion of anesthesia care WITHOUT complication is the fundamental goal of both

patients and anesthesia providers, suggesting that this metric is at the core of assessment for the specialties

involved.

Measure Steward




Measure Title:

ASA #11: Immediate Perioperative Cardiac Arrest

Measure Description

For all non-emergent surgical cases, the percentage of patients who experience a cardiac arrest* under the care of

an anesthesia provider in the OR or PACU.

* Cardiac arrest: Cardiac arrest is broadly defined as the cessation of cardiac mechanical activity as

confirmed by the absence of signs of circulation. For the present registry, subcommittee members agreed

that the definition should include the following use of cardiac compressions and/or defibrillation.

Reporting of the etiology of cardiac arrest, may include, but not be limited to:

a. Ventricular fibrillation

b. Rapid ventricular tachycardia with hemodynamic instability

c. Asystole

d. Extreme bradycardia with hemodynamic instability

NQS Domain

Patient Safety


Intermediate Outcome



Registry Codes are used to report the numerator of the measure.

**Note that a lower calculated performance rate for this measure indicates better clinical care or control.**

Denominator

All scheduled procedures receiving anesthesia.


Patient of any age

AND


Anesthesia codes which are commonly indicated for associated surgical procedure(s):

00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160,

00162, 00164, 00170, 00172, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00220,

00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454,

00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00539, 00540,

00541, 00542, 00546, 00548, 00550, 00560, 00600, 00620, 00625, 00626, 00630, 00632, 00635, 00640,

00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796,

00797, 00800, 00802, 00810, 00820, 00830, 00834, 00836, 00840, 00844, 00846, 00848, 00851, 00860,

00862, 00864, 00865, 00866, 00868, 00870, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910,

00912, 00914, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938,

00940, 00942, 00944, 00948, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180,

01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01250, 01260, 01270, 01272,

01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01440, 01442,

01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520,



01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680,

01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770,

01772, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01860, 01916, 01920,

01922, 01924, 01925, 01926, 01930, 01931, 01935, 01936, 01951, 01952, 01958, 01961, 01963, 01965,

01966,, 01990, 01991, 01992, 01999


Cases with planned cardiac arrest – deep hypothermia, electrophysiology cases, cardiac bypass cases

Emergent cases identified by ASA Physical Status indicating case is emergent by using ‘E’ designation

Numerator

Number of patients experiencing an unanticipated cardiac arrest.


Performance Met:

ASA11A: Patient experienced an unanticipated cardiac arrest

OR


ASA11B: Patient did not experience unanticipated cardiac arrest


Rationale

Cardiac arrest in the perioperative period is an unintended serious adverse event, associated with immediate

mortality of about 50%. Arrest can occur as the result of sudden physiologic disruption due to surgery or

medications (e.g. anaphylaxis, air embolus) or as the cumulative result of progressive deterioration (e.g. bleeding,

heart failure). Prevention of cardiac arrest is a core goal of anesthesia providers, with high face validity as a

discriminator of the quality of anesthesia care.

Measure Steward




Measure Title:

ASA #12: Immediate Perioperative Mortality Rate

Measure Description

For all non-emergent surgical cases, the percentage of patients who experience mortality under the care of an

anesthesia provider in the OR or PACU.

NQS Domain

Patient Safety


Outcome



CPT Category II and registry codes are used to report the numerator of the measure.

Note that a lower calculated performance rate for this measure indicates better clinical care or control.

Denominator

All scheduled procedures receiving anesthesia.


Patient of any age

AND



00100,00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160,

00162, 00164, 00170, 00172, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00220,

00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454,

00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539,

00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600,

00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752,

00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00834,

00836, 00840, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00873,

00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00918, 00920, 00921, 00922, 00924,

00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00952, 01112, 01120,

01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215,

01220, 01230, 01232, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390,

01392, 01400, 01402, 01404, 01420, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480,

01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636,

01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732,

01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01782, 01810, 01820, 01829, 01830, 01832,

01840, 01842, 01844, 01850, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01935,

01936, 01951, 01952, 01958, 01961, 01963, 01965, 01966, , , 01991, 01992, 01999




Organ Donors as designated by ASA Physical Status of 6

ASA Physical Status indicating case is emergent by using ‘E’ designation

Numerator

The number of deaths occurring during the immediate perioperative period.


Performance Met:

ASA12A: Patient died

OR


ASA12B: Patient did not die


Rationale

Mortality is the outcome of ultimate interest to patients and providers. Albeit very rare in the perioperative period,

death in the OR or PACU is a sentinel event in any anesthesia department, as the majority of such occurrences can

be traced directly to anesthetic management issues. Capturing this data in a uniform fashion will allow

assessment of variability across practices and facilities, as well as identification of the rare outlier at the individual

physician level.

Measure Steward




Measure Title:

ASA #13: Post Anesthesia Care Unit (PACU) Re-intubation Rate

Measure Description

Percentage of patients, regardless of age, who were extubated in the Operating Room or the PACU following

general anesthesia but required re-intubation prior to PACU discharge.

NQS Domain

Patient Safety



Instructions:

This measure is to be reported each time a patient who undergoes a procedure under general anesthesia has a

supraglottic airway (SGA) or endotracheal tube (ETT) placed for the procedure and then removed in the operating

room or PACU.



Registry codes are used to report the numerator of this measure.


Denominator

All patients, regardless of age, who undergo a procedure under general anesthesia facilitated by an SGA or ETT

who were extubated in the Operating Room or PACU.


Patient of any age

AND

Patient had a planned extubation following general anesthesia (ASA13F)

AND

Patient encounter during the reporting period (CPT): 00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148,

00160, 00162, 00164, 00170, 00172, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215,

00216, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406,

00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530,

00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562,

00563, 00566, 00567, 00580, 00600, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670,

00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796,

00797, 00800, 00802, 00810, 00820, 00830, 00834, 00836, 00840, 00844, 00846, 00848, 00851,

00860, 00862, 00864, 00865, 00866, 00868, 00870, 00873, 00880, 00882, 00902, 00904, 00906,

00908, 00910, 00912, 00914, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932,

00934, 00936, 00938, 00940, 00942, 00944, 00948, 00952, 01112, 01120, 01130, 01140, 01150,

01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230,

01232, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392,



01400, 01402, 01404, 01420, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480,

01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634,

01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716,

01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01782, 01810, 01820,

01829, 01830, 01832, 01840, 01842, 01844, 01850, 01860, 01916, 01920, 01922, 01924, 01925,

01926, 01930, 01931, 01935, 01936, 01951, 01952, 01958, 01961, 01963, 01965, 01966, 01967,

01990, 01991, 01992, 01999


Patients transferred directly to the Intensive Care Unit (ICU) from the Operating Room (OR).

Numerator

Patients who required new management with an Endotracheal Tube (ETT), supraglottic airway (SGA) or new

surgical airway prior to PACU discharge


Performance Met:

ASA13A: Patient required new airway management prior to PACU discharge.

Performance Not Met

ASA13B: Patient did not require new airway management prior to PACU discharge.

Performance Not Met – Medical Performance Exclusion

ASA13G: Patient received a planned trial of extubation documented in the medical record

prior to removal of the original airway device

Rationale

The need for early repeat airway management of surgical patients is strongly associated with subsequent serious

adverse outcomes; prolonged ICU and hospital stay, and increased costs of care. Assessment of this metric under

a unified definition will be an important tool for benchmarking the performance of surgical facilities, anesthesia

departments, and individual practitioners.

Measure Steward




Measure Title:

ASA #14: Short-term Pain Management Measure Description The number of patients aged 10 years or older admitted to the PACU following an anesthetic with a pain score

< 7 (out of 10).

NQS Domain




Instructions:

This measure is to be reported each time a patient is admitted to the PACU following a procedure that included an

anesthetic during the reporting period.



Registry codes are used to identify the numerator.

Denominator

All patients age 10 years and older admitted to PACU who are assessed for pain.


Patients age 10 years or older

AND Patient can be assessed for pain (ASA14G)

AND



00100,00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160,

00162, 00164, 00170, 00172, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00220,

00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454,

00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539,

00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600,

00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752,

00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00834,

00836, 00840, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00873,

00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00918, 00920, 00921, 00922, 00924,

00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00952, 01112, 01120,

01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215,

01220, 01230, 01232, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390,

01392, 01400, 01402, 01404, 01420, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480,

01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636,

01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732,

01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01782, 01810, 01820, 01829, 01830, 01832,



01840, 01842, 01844, 01850, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01935,

01936, 01951, 01952, 01958, 01961, 01963, 01965, 01966, 01990, 01991, 01992, 01999


None

Numerator

The number of lucid patients with an initial pain score < 7/10


Performance Met:

ASA14B: Patient did not experience pain > 7 out of 10

Patient Performance Exclusion:

ASA14D: Patient could not be assessed for pain (e.g. Patient with major psychiatric

disorders, chronic pain patients and patients who do not speak English or present

a language barrier).

OR


ASA14A: Patient did experience pain > 7 out of 10

Rationale

Alleviation of pain is a core responsibility of the anesthesia provider, and adequate postoperative pain control is

an important component of patient satisfaction with anesthesia and surgery. A large body of literature exists to

support evidence-based practice in this area. Significant variability in outcomes exists at the practice, facility and

individual provider level. Capture of this metric under a common definition will greatly enhance anesthesia

quality management and lead directly to improvements in patient outcome.

Measure Steward




Measure Title:

ASA #15: Composite Procedural Safety for Central Line Placement

Measure Description

Percentage of patients, regardless of age, who did not experience pneumothorax or arterial injury following

attempted central venous cannulation.

NQS Domain

Patient Safety



Instructions:

This measure is to be reported each time a central venous cannulation (CVC) is attempted during the reporting

period. There is no diagnosis associated with this measure. It is anticipated that clinicians who attempt CVC

insertions will submit this measure.



CPT Category codes are used to report the numerator of the measure.

Denominator

All patients, regardless of age, who undergo CVC insertion.



36563, 36565, 36566, 36568, 36569, 36570, 36571, 36575, 36576, 36578, 36580, 36581, 36582, 36583,

36584, 36585, 36589, 36590, 36592, 36595, 36596, 36597, 36598, 75901, 75902, 93503

Denominator Exclusions

None

Numerator

Patients who did not experience and arterial injury or pneumothorax requiring thoracostomy placement or

decompression of the pleural cavity (from the medical record or PSI code).


Performance Met:

ASA15B: Patient did not experience an arterial injury or pneumothorax requiring

thoracostomy placement.

OR

Medical Performance Exclusion:

ASA15C: Emergent Cases

OR



Performance Not Met

ASA15A: Patient did experience an arterial injury or pneumothorax requiring

thoracostomy placement

OR

Patient encounter during the reporting period (CPT): 32035, 32036, 32551

Rationale

Central venous cannulation is commonly required for anesthesia patients but may be associated with serious

adverse events. Arterial injury and pneumothorax each require additional treatment that adds to the cost and

discomfort of care. Recent scientific literature has documented that the risk for these complications can be

reduced through evidence-based practice, including the use of ultrasound localization of the central vein. This

measure will allow for documentation of variability in occurrence of this outcome, and will empower quality

improvement efforts.

Measure Steward




Measure Title:

ASA #16: Composite Patient Experience

Measure Description

Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with

anesthesia care (e.g. private vendor assessment of patient experience and satisfaction, Consumer Assessment of

Healthcare Providers and Systems Surgical Care Survey or S-CAHPS).

NQS Domain



Process

Instructions:

This measure is to be reported each time a patient underwent a procedure with anesthesia


CPT codes and patient demographics are used to identify patients who are included in the measrure denominator.

Registry codes are used to report the measure numerator.

Denominator

Patients, aged 18 and older, who undergo a procedure* under anesthesia.

Definition:

Any procedure including surgical, therapeutic or diagnostic


Patient aged 18 and older

AND

Patient encounter during the reporting period (CPT): 00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148,

00160, 00162, 00164, 00170, 00172, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215,

00216, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406,

00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530,

00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562,

00563, 00566, 00567, 00580, 00600, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670,

00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796,

00797, 00800, 00802, 00810, 00820, 00830, 00834, 00836, 00840, 00844, 00846, 00848, 00851,

00860, 00862, 00864, 00865, 00866, 00868, 00870, 00873, 00880, 00882, 00902, 00904, 00906,

00908, 00910, 00912, 00914, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932,



00934, 00936, 00938, 00940, 00942, 00944, 00948, 00952, 01112, 01120, 01130, 01140, 01150,

01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230,

01232, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392,

01400, 01402, 01404, 01420, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480,

01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634,

01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716,

01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01782, 01810, 01820,

01829, 01830, 01832, 01840, 01842, 01844, 01850, 01860, 01916, 01920, 01922, 01924, 01925,

01926, 01930, 01931, 01935, 01936, 01951, 01952, 01958, 01961, 01963, 01965, 01966, 01967,

01990, 01991, 01992, 01999


Emergent cases

Numerator

Patients who received a survey* or similar tool used to assess their experience and satisfaction with anesthesia.

Definition:

* The survey tool used must reflect and take into consideration the recommendations of the ASA

Committee on Performance and Outcomes Measurement work product entitled “Patient Satisfaction and

Experience with Anesthesia.”


Performance Met:

ASA16A: Patient provided with a survey or similar tool to assess their experience and

satisfaction with anesthesia

OR

Performance Not Met

ASA16B: Patient was not provided with a survey or similar tool to assess their

experience and satisfaction with anesthesia

OR


ASA16F: Patient unable to be surveyed because of cognitive impairment or major

psychiatric disorder.

OR


ASA16G: Provider unable to send patient survey or similar tool in patient’s preferred

language

Rationale

Patient-centered outcomes are important discriminators of the quality of anesthesia practice. Anesthesia

departments and individual providers should have access to relevant S-CAHPS data collected by the facility or

practice as a means of guiding quality improvement initiatives.

Measure Steward



http://www.aqihq.org/files/2014-06-09_CPOM%20Patient%20Satisfaction%20and%20Experience_White%20Paper_FINAL%20Revised.pdf

http://www.aqihq.org/files/2014-06-09_CPOM%20Patient%20Satisfaction%20and%20Experience_White%20Paper_FINAL%20Revised.pdf


Measure Title

*ASA #17: Perioperative Care: Timely Administration of Prophylactic Parenteral

Antibiotics (NQF 269)

Measure Description

Percentage of surgical patients aged 18 years and older who receive an anesthetic when undergoing procedures

with the indications for prophylactic parenteral antibiotics for whom administration of a prophylactic parenteral

antibiotic ordered has been initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to the

surgical incision (or start of procedure when no incision is required)

NQS Domain

Patient Safety


Process

Instructions:

This measure is to be reported each time an anesthesia service in the denominator is provided for surgical patients

during the reporting period. There is no diagnosis associated with this measure. It is anticipated that clinicians

who provide anesthesia services, as specified in the denominator coding*, will submit this measure - reporting on

the timeliness of parenteral antibiotic administration. The clinician providing anesthesia services does not need to

be the clinician who ordered the prophylactic parenteral antibiotic.

*The anesthesia services included in the denominator are associated with some surgical procedures for which

prophylactic parenteral antibiotics may not be indicated. As a result, clinicians should report 4047F-8P for those

instances in which anesthesia services are provided but not associated with surgical procedures for which

prophylactic parenteral antibiotics are indicated.

If the clinician providing anesthesia services orders AND administers the prophylactic parenteral antibiotic within

the appropriate timeframe, report quality-data code CPT II 4048F. Report CPT II 4048F with the 1P modifier in

circumstances where the prophylactic parenteral antibiotic was not given for medical reasons (eg, contraindicated,

patient already receiving antibiotics).


CPT codes and patient demographics are used to identify patients who are included in the measure’s denominator.


When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT Category II code

OR the appropriate CPT Category II code with the modifier. The modifiers allowed for this measure are: 1P-

medical reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported on the

claim(s) representing the eligible encounter as the denominator codes.

Denominator

All surgical patients aged 18 years and older who receive an anesthetic when undergoing procedures* with the

indications for prophylactic parenteral antibiotics

DENOMINATOR NOTE: Anesthesia services included in denominator are associated with some

surgical procedures for which prophylactic parenteral antibiotics may not be indicated. Clinicians should



report 4047F-8P for those instances in which anesthesia services are provided but not associated with

surgical procedures for which prophylactic parenteral antibiotics are indicated.


Patients aged ≥ 18 years on date of encounter

AND

Patient encounter during the reporting period (CPT): Anesthesia codes for which prophylactic parenteral

antibiotics are commonly indicated for associated surgical procedure(s):

00100, 00102, 00103, 00120, 00140, 00145, 00147, 00160, 00162, 00164, 00170, 00172, 00174, 00176,

00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322,

00350, 00352, 00400, 00402, 00404, 00406, 00450, 00454, 00470, 00472, 00474, 00500, 00528, 00529,

00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562,

00563, 00566, 00567, 00580, 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00670, 00700, 00730,

00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00820, 00830,

00832, 00840, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00880,

00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924,

00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 01120, 01140, 01150, 01170,

01173, 01180, 01190, 01202, 01210, 01212, 01214, 01215, 01230, 01232, 01234, 01250, 01260, 01270,

01272, 01274, 01320, 01360, 01382, 01392, 01400, 01402, 01404, 01430, 01432, 01440, 01442, 01444,

01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01500, 01502, 01520, 01522, 01610, 01622,

01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01710, 01712, 01714, 01716, 01732,

01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01829, 01830, 01832,

01840, 01842, 01844, 01850, 01852, 01924, 01925, 01926, 01951, 01952, 01953, 01961, 01962, 01963,

01965, 01966, 01968, 01969


None

Numerator

Surgical patients for whom administration of a prophylactic parenteral antibiotic ordered has been initiated within

one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when

no incision is required)

Numerator Instructions: This measure seeks to identify the timely administration of prophylactic

parenteral antibiotic. This administration should begin within one hour (if fluoroquinolone or

vancomycin, two hours) prior to surgical incision.

Numerator Quality-Data Coding Options for Reporting Satisfactorily: The antimicrobial drugs listed below are considered prophylactic parenteral antibiotics for the purposes of

this measure. 4048F-8P should be reported when antibiotics from this table were not ordered.

Ampicillin/sulbactam

Aztreonam

Cefazolin

Cefmetazole

Cefotetan

Cefoxitin

Cefuroxime

Ciprofloxacin

Clindamycin

Ertapenem

Erythromycin base

Fluoroquinolone

Gatifloxacin

Gentamicin

Levofloxacin

Metronidazole

Moxifloxacin

Neomycin

Pipericillin/tazobactam

Vancomycin



NUMERATOR NOTE: “Ordered” includes instances in which the prophylactic parenteral antibiotic is

ordered by the clinician performing the surgical procedure OR is ordered by the clinician providing the

anesthesia services.

Documentation that Prophylactic Parenteral Antibiotic was Administered Within Specified

Timeframe

Performance Met: CPT II 4048F: Documentation that administration of prophylactic parenteral

antibiotic was initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to

surgical incision (or start of procedure when no incision is required) as ordered OR

Prophylactic Parenteral Antibiotic not Administered for Medical Reasons (eg,

contraindicated, patient already receiving antibiotics)

Append a modifier (1P) to CPT Category II code 4048F to report documented circumstances that

appropriately exclude patients from the denominator. Medical Performance Exclusion: 4048F with 1P: Documentation of medical reason(s) for not initiating

administration of prophylactic parenteral antibiotics as specified (eg, contraindicated,

patient already receiving antibiotics)

OR

If patient is not eligible for this measure because prophylactic parenteral antibiotic not ordered,

report:

Prophylactic Parenteral Antibiotic not Ordered

Append a reporting modifier (8P) to CPT Category II code 4047F to report circumstances when the

patient is not eligible for the measure.

Other Performance Exclusion: 4047F with 8P: No documentation of order for prophylactic

parenteral antibiotics to be given within one hour (if fluoroquinolone or

vancomycin, two hours) prior to surgical incision (or start of procedure when no

incision is required) OR

Prophylactic Parenteral Antibiotic Ordered but not Initiated Within One Hour, Reason not

Otherwise Specified

Append a reporting modifier (8P) to CPT Category II code 4048F to report circumstances when

the action described in the numerator is not performed and the reason is not otherwise specified. Performance Not Met: 4048F with 8P: Administration of prophylactic parenteral antibiotic was not

initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to the

surgical incision (or start of procedure when no incision is required), reason not otherwise

specified

Rationale:

The appropriate timing of administration of prophylactic parenteral antibiotics has been demonstrated to reduce

the incidence of surgical wound infections. Available evidence suggests that although most surgical patients

receive a prophylactic antibiotic, many do not receive the drug within one hour before incision as recommended.

Clinical Recommendation Statement:

Overall, administration of the first dose of antimicrobial beginning within 60 minutes before surgical incision is

recommended. Administration of vancomycin and fluoroquinolones should begin within 120 minutes before

surgical incision because of the prolonged infusion times required for these drugs. (ASHP, 2013)



Infusion of the first antimicrobial dose should begin within 60 minutes before incision. However, when a

fluoroquinolone or vancomycin is indicated, the infusion should begin within 120 minutes

before incision to

prevent antibiotic-associated reactions. Although research

has demonstrated that administration

of the

antimicrobial at the time of anesthesia

induction is safe and

results in adequate serum

and tissue drug levels

at the

time of incision, there was no

consensus that the infusion

must be completed before

incision. (SIPGWW, 2004)

Measure Steward




Measure Title

*ASA #18: Perioperative Temperature Management (Submitted for NQF Endorsement 1/2015)

Measure Description

Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or

neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or

equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately

before or the 15 minutes immediately after anesthesia end time

NQS Domain

Patient Safety



Instructions:

This measure is to be reported each time a surgical or therapeutic procedure not involving cardiopulmonary

bypass is performed under general or neuraxial anesthesia during the reporting period. There is no diagnosis

associated with this measure. It is anticipated that clinicians who provide the listed anesthesia services as

specified in the denominator coding will submit this measure.








Denominator

All patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial

anesthesia of 60 minutes duration or longer


CPT II 4255F: Duration of general or neuraxial anesthesia 60 minutes or longer, as documented in the

anesthesia record

AND

Patient encounter during the reporting period (CPT): 00100, 00102, 00103, 00104, 00120, 00124, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147,

00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214,

00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404,

00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530,

00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00600, 00604, 00620,

00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754,

00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, 00834,

00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870,

00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920,



00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948,

00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202,

01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320,

01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442,

01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520,

01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680,

01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770,

01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860,

01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01961, 01962, 01963,

01965, 01966, 01968, 01969


Patients undergoing :

Cardiopulmonary bypass : 00561, 00562, 00563, 00566, 00567, 00580

Regional nerve block : 01958, 01960, 01967, 01991, 01992

Monitored anesthesia care : any CPT code with -QS modifier

Numerator

Patients for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees

Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after

anesthesia end time


Performance Met:

CPT® II 4559F: At least one body temperature greater than or equal to 35.5 degrees

Celsius (or 95.9 degrees Fahrenheit) recorded within the 30 minutes

immediately before or the 15 minutes immediately after anesthesia end

time

OR

At Least One Body Temperature Equal to or Greater than 35.5 Degrees Centigrade not Achieved

within Designated Timeframe for one of the following Medical Reasons – Medical Performance

Exclusion:

CPT® II 4559F-1P: Documentation of one of the following medical reason(s) for not

achieving at least one body temperature greater than or equal to

35.5 degrees Centigrade or 95.9 degrees Fahrenheit within the 30

minutes immediately before or the 15 minutes immediately after

anesthesia end time

Emergency cases

Intentional hypothermia

OR

At Least One Body Temperature Equal to or Greater than 35.5 Degrees Centigrade not Achieved

within Designated Timeframe, Reason Not Otherwise Specified

CPT ® II 4559F-8P: At least one body temperature greater than or equal to 35.5

degrees Celsius (or 95.9 degrees Fahrenheit) not recorded within

the 30 minutes immediately before or the 15 minutes immediately

after anesthesia end time



Rationale

A drop in core temperature during surgery, known as perioperative hypothermia, can result in numerous adverse

effects, which can include adverse myocardial outcomes, subcutaneous vasoconstriction, increased incidence of

surgical site infection, and impaired healing of wounds. The desired outcome, reduction in adverse surgical

effects due to perioperative hypothermia, is affected by maintenance of normothermia during surgery.

Unintended perioperative hypothermia occurs in up to 20% of surgical patients. An observational cohort study in

a pediatric setting found that more than 50% of children experienced intraoperative hypothermia. Pediatric

patients undergoing major surgery were at greater risk of intraoperative hypothermia.



American College of Cardiology Foundation/American Heart Association recommend:

Maintenance of body temperature in a normothermic range is recommended for most procedures other than

during periods in which mild hypothermia is intended to provide organ protection (e.g., during high aortic cross-

clamping) (Class I, Level B)

Measure Steward




Measure Title

*ASA #19: Perioperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents

Measure Description

Percentage of patients, aged 18 years and older with a pre-existing drug-eluting coronary stent, who undergo a

surgical or therapeutic procedure under anesthesia, who receive aspirin 24 hours prior to anesthesia start time

NQS Domain

Patient Safety


Process

Instructions:

This measure is to be reported each time a patient with a pre-existing drug-eluting coronary stent undergoes a

surgical or therapeutic procedure under anesthesia within the reporting period.


CPT codes, CPT II codes, and patient demographics are used to identify patients who are included in the

measure's denominator. CPT Category II codes are used to report the numerator of the measure.

Denominator

All patients, aged 18 years and older, with a pre-existing drug-eluting coronary stent, who undergo a surgical or

therapeutic procedure under anesthesia



AND

CPT II Code 4561F: Patient has a coronary artery stent

AND


00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172,

00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300,

00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472,

00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541,

00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600, 00604, 00620,

00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754,

00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, 00834,

00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870,

00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920,

00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948,

00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202,

01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320,

01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442,

01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520,

01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680,

01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770,

01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860,



01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01961, 01962, 01963,

01965, 01966, 01968, 01969, 01991, 01992

Denominator Exclusions

None

Numerator

Patients who receive* aspirin 24 hours prior to anesthesia start time

Definition:

* Patient reports taking aspirin OR hospital staff administered aspirin

Numerator Quality-Data Coding Options for Reporting Satisfactorily:

Performance Met:

CPT II 4563F: Patient received aspirin within 24 hours prior to anesthesia start

time

OR

Patient Did Not Receive Aspirin Within 24 Hours Prior to Anesthesia Start Time – Medical

Performance Exclusion:

CPT II 4563F-1P: Documentation of medical reason(s) for not receiving aspirin 24

hours prior to anesthesia start time (e.g., risks of preoperative

aspirin therapy are greater than the risks of withholding aspirin,

other medical reasons)

OR

Patient Did Not Receive Aspirin Within 24 Hours Prior to Anesthesia Start Time – Reason

Unspecified:

CPT II 4563F-8P Patient did not receive aspirin within 24 hours prior to anesthesia

start time, reason not otherwise specified

Rationale

Late stent thrombosis is a relatively rare but serious complication of stent placement, with an estimated case

fatality rate of up to 45%. Multiple studies have shown that premature discontinuation of dual antiplatelet therapy

is associated with increased risk of stent thrombosis in patients with drug-eluting stents. Late stent thrombosis, or

thrombosis >1 year after stent placement, is of particular concern for drug-eluting stents. This concern indicates a

need for a longer course of dual antiplatelet therapy for patients with drug-eluting stents compared to those with

bare metal stents.



American College of Cardiology and American Heart Association (ACC/AHA) recommendation:

In patients who have received drug-eluting coronary stents and who must undergo urgent surgical procedures that

mandate the discontinuation of thienopyridine therapy, it is reasonable to continue aspirin if at all possible and

restart the thienopyridine as soon as possible. (Class IIa, Level of Evidence: C)

For patients treated with DES who are to undergo subsequent procedures that mandate discontinuation of

thienopyridine therapy, aspirin should be continued if at all possible and the thienopyridine restarted as soon as

possible after the procedure because of concerns about late-stent thrombosis.



Measure Steward




Measure Title

*ASA #20: Surgical Safety Checklist – Applicable Safety Checks Completed Before Induction of Anesthesia

Measure Description

Percentage of patients, regardless of age, who undergo a surgical procedure under anesthesia who have

documentation that all applicable safety checks from the World Health Organization (WHO) Surgical Safety

Checklist (or other surgical checklist that includes the applicable safety checks for the specific procedure) were

performed before induction of anesthesia

NQS Domain

Patient Safety


Process

Instructions:

This measure is to be reported each time a patient undergoes a surgical procedure under anesthesia.


For this measure, report the appropriate registry codes for each patient for whom all applicable safety checks of

the WHO Surgical Safety Checklist (or other surgical checklist that includes the safety checks for specific

procedure) were performed before induction of anesthesia.

Denominator

All patients, regardless of age, who undergo a surgical procedure under anesthesia



00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172,

00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300,

00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472,

00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541,

00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600, 00604, 00620,

00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754,

00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, 00834,

00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870,

00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920,

00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948,

00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202,

01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320,

01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442,

01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520,

01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680,

01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770,

01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860,

01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01961, 01962, 01963,

01965, 01966, 01968, 01969, 01991, 01992




None

Numerator

Patients who have documentation that all applicable safety checks of the WHO Surgical Safety Checklist (or other

surgical checklist that includes the safety checks for specific procedure) were performed before induction of

anesthesia

Definition:

The WHO Surgical Safety Checklist includes the following items

Before Induction of Anesthesia

Has the patient confirmed his/her identity, site, procedure and consent?

Is the site marked?

Is the anaesthesia machine and medication check complete?

Is the pulse oximeter on the Patient And Functioning?

Does the Patient have a:

o Known Allergy?

o Difficult Airway/Aspiration Risk?

o Risk of >500 ml Blood Loss (7ml/kg in children)?

Numerator Quality-Data Coding Options for Reporting Satisfactorily:

Performance Met – Documented Use of WHO Surgical Safety Checklist:

ASA20A: All applicable safety checks of the WHO Surgical Safety Checklist (or other

surgical checklist that includes the safety checks for specific procedure)


OR

Performance Not Met

ASA20B: All applicable safety checks of the WHO Surgical Safety Checklist (or other

surgical checklist that includes the safety checks for specific procedure) NOT


Rationale

In 2009, the World Health Organization (WHO) Safe Surgery Saves Lives Study Group published a study

showing that utilization of a surgical safety checklist resulted in reduced perioperative mortality and complication

rates. Since then, surgical safety checklists have been widely implemented around the world. Further studies

confirm the WHO findings that implementation of the surgical safety checklist improves communication among

members of the surgical team and reduces perioperative morbidity and mortality.

While the number of surgery-related sentinel events has decreased over the past several years, operative care still

remains one of the top ten root causes for sentinel events. To address patient safety concerns in the operating

room, surgical safety checklists have been widely implemented in recent years. However, compliance with

surgical safety checklists and safety checklist protocols has been shown to vary widely. The level of checklist

compliance has been shown to vary depending on the implementation strategy.




WHO Guidelines for Safe Surgery

The World Health Organization’s Surgical Safety Checklist reinforces established safety practices and ensures

beneficial preoperative, intraoperative and postoperative steps are undertaken in a timely and efficient way.

Introducing key safety elements into the operating routine, teams could maximize the likelihood of the best

outcome for all surgical patients without placing an undue burden on the system or the providers.

WHO Surgical Safety Checklist is available at http://www.who.int/patientsafety/safesurgery/en/

Measure Steward



http://www.who.int/patientsafety/safesurgery/en/


Measure Title

ASA #21: Smoking Abstinence

Measure Description

Percentage of current smokers who abstain from smoking cigarettes prior to anesthesia on the day of elective

surgery or procedure.

NQS Domain




Instructions:

This measure is to be reported each time a patient who is a current smoker is evaluated in preparation for elective

surgical, diagnostic, or pain procedure with instructions from a clinician to abstain from smoking on the day of

surgery and is evaluated for smoking abstinence on the day of surgery. It is expected that anesthesia providers

would either incorporate this advice as a part of the preoperative evaluation center or in collaboration with

surgeons and proceduralists to ensure that instructions to stop smoking occur prior to surgery. The anesthesia

provider would confirm smoking status of the patient on the day of surgery.


Patient demographics are used to identify patients who are included in the measure's denominator. Registry codes

are used to identify the measure numerator.

Denominator

All patients aged 18 years and older who are evaluated in preparation for elective surgical, diagnostic, or pain

procedure in settings that include routine screening for smoking status with instruction to abstain from smoking

on the day of surgery or procedure.


All patients, aged 18 years and older

AND

Are evaluated in preparation for elective surgical, diagnostic, or pain procedure in settings that include

routine screening for smoking status with instruction to abstain from smoking on the day of surgery or

procedure (ASA21A)

AND

Current cigarette smokers (ASA21B)


None

Numerator

Patients who abstained from smoking prior to anesthesia on the day of surgery or procedure*.

Definition:

Smoking abstinence is defined by either patient self-report or an exhaled carbon monoxide level of <10

ppm.




Performance Met:

ASA21C: Patient abstained from smoking prior to anesthesia on

the day of surgery or procedure


ASA21D: Patient did NOT abstain from smoking prior to

anesthesia on the day of surgery or procedure.

Rationale

Each year, millions of cigarette smokers require surgery and anesthesia in the US. Smoking is a significant

independent risk factor for perioperative heart, lung, and wound-related complications. There now is good

evidence that perioperative abstinence from smoking reduces the risk of heart, lung, and wound-related

perioperative complications, and that the perioperative period represents a “teachable moment” for smoking

cessation that improves long-term abstinence rates; over 100,000 smokers quit in the US each year as a result of

having a surgical procedure. Although evidence suggests that the longer the duration of abstinence the better,

there is also evidence that even brief abstinence (e.g., abstaining from smoking on the morning of surgery) can

dramatically reduce both nicotine and carbon monoxide levels and reduce risks for complications such as

intraoperative myocardial ischemia. Evidence shows that tobacco interventions can 1) increase perioperative

abstinence rates in surigical patients who smoke and 2) decrease the rate of perioperative complications. Thus,

this measure, which incents the provision of tobacco interventions by clinicians as a part of routine clinical

practice, will significantly improve the health of smokers who require surgery.


In its Clinical Practice Guideline for Treating Tobacco Use and Dependence, the US Public Health Services

recognizes the important role that clinicians play in delivering tobacco use intervention services, strongly

recommending that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for

those who use tobacco products.

Measure Steward




Measure Title

ASA #22: Corneal Injury Diagnosed in the Post-Anesthesia Care Unit/Recovery Area

after Anesthesia Care (Inverse Measure)

Measure Description

The percentage of patients, aged 18 years and older, who undergo anesthesia care who have a diagnosis of corneal

injury in the post-anesthesia care unit/recovery area.

NQS Domain

Patient Safety


Process

Instructions:

This measure is to be reported each time a patient underwent a procedure* with anesthesia not involving patients

with pre-existing eye trauma or those patients undergoing ophthalmologic surgery.



Registry codes are used to report the measure numerator.

Denominator

All patients, aged 18 and older, who undergo anesthesia care, except those with pre-existing eye trauma or those

patients undergoing ophthalmologic surgery.



AND

Patient encounter during the reporting period (CPT): 00100, 00102, 00104, 00120, 00124, 00120, 00124, 00126, 00160, 00162, 00164, 00170, 00172, 00174,

00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320,

00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474,

00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542,

00546, 00548, 00550, 00560, 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670,

00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797,

00800, 00802, 00810, 00820, 00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851,

00860, 00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906,

00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932,

00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150,

01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232,

01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400,

01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480,

01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636,

01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732,

01740, 01742, 01744,01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830,

01832, 01840, 01842, 01844, 01850, 01852, 01860, 01924, 01925, 01926, 01930, 01931, 01932, 01933,

01935, 01936, 01951, 01952, 01961, 01962, 01963, 01965, 01966, 01968, 01969



Denominator Exclusions / Exceptions Patients who undergo ophthalmologic surgery or patients with a diagnosis of either eye trauma or corneal injury

before anesthesia care.

Numerator

All patients who undergo anesthesia care and have a diagnosis of corneal injury in the post-anesthesia

care unit/recovery area.

Definition:

Corneal Injury: Includes both exposure keratitis and corneal abrasion. For the purposes of this

measure, the distinction does not need to be made with fluorescein examination of the cornea under

ultraviolet light; however, it can be diagnosed in this manner. Corneal injury also includes any new

symptom of eye pain treated with topical antibiotic (e.g., erythromycin) while in the post-anesthesia care

unit/recovery area. Other causes of eye pain (e.g. acute angle-closure glaucoma) can be excluded by

instilling one drop of local anesthetic (e.g., proparacaine) into the eye. If the pain is immediately and

completely relieved, corneal injury is confirmed and acute angle-closure glaucoma is excluded.


Performance Met:

ASA22A: Patient diagnosed with exposure keratitis or corneal abrasion in the post-

anesthesia care unit or recovery room.

OR

Performance Not Met – Medical Performance Exclusion:

ASA22B: Patient NOT diagnosed with exposure keratitis or corneal abrasion in the post-

anesthesia care unit or recovery room.

Rationale

Corneal abrasion/injury is the most common ophthalmologic complication that occurs during general anesthesia

for non-ocular surgery. These injuries are usually just painful for the patient, but can lead to significant microbial

keratitis with possibility of permanent scarring. There is no standardized method for protecting the eyes during an

anesthetic for non-ocular surgery. Adhesive tape, individual single, sterile packaged eye covers, small bio-

occlusive dressings, used with or without eye ointment are some of the options used. Some practitioners may

simply observe closed, non-taped eyes. The specific type of eye ointment also varies significantly. Some ointment

is made with petrolatum, some is water soluble, with or without preservatives. If ointment is used, preservative-

free eye ointment is preferred, because preservative can cause corneal epithelial sloughing and conjunctiva

hyperemia. None of the methods described in the literature are entirely effective at preventing corneal injury and

some are associated with unwanted side effects. It is important to know that petrolatum is flammable and should

be avoided when cautery will be used near the face. Several large studies have demonstrated that applying these

techniques while measuring performance can lead to significant improvements in patient care. Measuring the

incidence of corneal injury will give practices the data they need to assess performance, compare to national

benchmarks, and if gaps are identified, undertake measures to improve eye protection for patients. The net result

will be reduced corneal injuries and patient discomfort. All eye trauma cases and all eye surgery cases will be

excluded from the measure. Reporting separately those procedures done on the face, including the ear, nose, and

mandible, will serve as stratification allowing comparison of procedures which most anesthesiologists believe

have a higher risk of corneal injury and which also remove the eyes from the direct control of the anesthesiologist.

Measure Steward




Measure Title

ASA #23: Coronary Artery Bypass Graft (CABG): Prolonged Intubation

Measure Description

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative

intubation > 24 hours

NQS Domain



Outcome

Instructions:

This measure is to be reported each time a patient an isolated CABG procedure is performed during the reporting

period. It is anticipated that eligible professionals who provide services, identified by CPT Codes listed below, for

isolated CABG will submit this measure. This measure is intended to reflect the quality of surgical services

provided for isolated CABG or isolated reoperation CABG patients. Isolated CABG refers to CABG using arterial

and/or venous grafts only.



The measure must capture both the surgical and related anesthesia code. G-codes are used to report the numerator

of the measure. Note that a lower calculated performance rate for this measure indicates better clinical care or

control.

Denominator


All patients aged ≥ 18 years on date of encounter

AND

Patient encounter during the reporting period (CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33533,

33534, 33535, 33536

AND

00566, 00567

OR


33534, 33535, 33536

AND

Patient encounter during the reporting period (CPT): 33530

AND

00562


None



Numerator

Patients undergoing isolated CABG who require intubation > 24 hours following exit from the operating room


Performance Met:

Prolonged postoperative intubation (> 24 hrs) required (G8569)

OR

Performance Not Met: Prolonged postoperative intubation (> 24 hrs) not required (G8570)

Rationale

Based on an STS coronary artery bypass graft (CABG) study population, the morbidity rate associated with

prolonged intubation following CABG is 5.96%. Also, prolonged ventilation (defined as > 24 hours) was an

independent predictor for readmission to the ICU following CABG surgery (OR=10.53; CI: 6.18 to 17.91).

Shorter ventilation times are linked to high quality of care (ie, reduced in-hospital and operative mortality, as well

as better long-term outcomes as compared to prolonged ventilation).


Extubation greater than (>) 24 hours postoperatively is considered a “pulmonary complication”. Patients who

were extubated more than 24 hours after surgery had a longer duration of hospital stay and a greater incidence of

postoperative complications.

Measure Steward




Measure Title

ASA #24: Coronary Artery Bypass Graft (CABG): Stroke Measure Description

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative

stroke (ie, any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain)

that did not resolve within 24 hours

NQS Domain



Outcome

Instructions:










control.

Denominator



AND


33534, 33535, 33536

AND

00566, 00567

OR


33534, 33535, 33536

AND


AND

00562


None



Numerator

Patients undergoing isolated CABG surgery who have a postoperative stroke (ie, any confirmed neurological

deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours

Numerator Instructions: A lower calculated performance rate for this measure indicates better clinical care.


Performance Met:

Stroke following isolated CABG surgery (G8573)

OR


No stroke following isolated CABG surgery (G8574)

Rationale

Stroke is a devastating complication after coronary bypass surgery. The 1999 American College of

Cardiology/American Heart Association (ACC/AHA) guidelines indicate that adverse cerebral outcomes are

observed in ~6% of patients after bypass surgery equally divided between 2 types:

1) associated with major, focal neurological defects, stupor or coma and 2) evidence of deterioration in

intellectual function. Type 1 deficits occur in ~3% of patients and are responsible for 21% mortality.

Reports in the literature on postoperative stroke incidence are difficult to compare because the conditions included

in the term “stroke” vary. A standardized definition of stoke will provide common language to compare stroke

incidence and evaluate management strategies for reducing this devastating complication.

Reported rates of postoperative cerebral dysfunction range from 0.4% to 13.8% following coronary operations.

Complications for patients undergoing emergent CABG or valve surgery were greater than the complication rate

for patients undergoing elective CABG or valve surgery. As bypass times increased, so did the incidence of

stroke. When bypass time was 90 to 113 minutes, OR =1.59, p=0.022 and when bypass time was > 114 minutes,

the OR =2.59, p < 0.001. Outcomes are better when patient age is younger and with beating-heart surgery rather

than on-pump surgery.


The 1999 ACC/AHA guidelines describe strategies for reducing the risk of postoperative stroke such as an

aggressive approach to the management of patients with severely diseased ascending aortas identified by

intraoperative echocardiographic imaging, prevention or aggressive management of postoperative atrial

fibrillation, delay of bypass surgery in the case of a left ventricular mural thrombus or a recent, preoperative CVA

and preoperative carotid screening. Patients should carefully be screened for cerebrovascular disease to help

prevent stroke and its associated morbidities.

Measure Steward




Measure Title

ASA #25: Coronary Artery Bypass Graft (CABG): Post-Operative Renal Failure Measure Description

Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal

failure) who develop postoperative renal failure or require dialysis

NQS Domain



Outcome

Instructions:










control.

Denominator



AND


33534, 33535, 33536

AND

00566, 00567

OR


33534, 33535, 33536

AND


AND

00562


None



Numerator

Patients who develop postoperative renal failure or require dialysis; (Definition of renal failure/dialysis

requirement - patient had acute renal failure or worsening renal function resulting in one of the following: 1)

increase of serum creatinine to ≥ 4.0 mg/dL or 3x most recent preoperative creatinine level (acute rise must be at

least 0.5 mg/dL), or 2) a new requirement for dialysis postoperatively)

Performance Met:

Developed postoperative renal failure or required dialysis (G8575)

OR


No postoperative renal failure/dialysis not required (G8576)

Rationale

In 2000, coronary artery bypass graft (CABG) surgery was performed on more than 350,000 patients at a cost of

close to $20 billion. Some degree of Acute Renal Dysfunction (ARD) occurs in about 8% of patients following

CABG, and dialysis-dependent renal failure occurs in 0.7% to 3.5% of patients receiving CABG. The latter is

associated with substantial increases in morbidity, length of stay, and mortality (odds ratios for mortality range

from 15 to 27). ARD is associated with increased morbidity, mortality and length of stay in an ICU following

surgery. In addition, Acute Renal Failure occurs in 1.5% of patients undergoing any type of cardiac surgery.

There has been a substantial increase in postoperative morbidity, mortality, and cost associated with this relatively

common complication, regardless of whether or not this incidence varies much between providers, and there are

implications of even a modest decrease in its incidence.


Acute renal failure following CABG is an intermediate outcome measure for mortality since this complication is

independently associated (OR=27) with early mortality following cardiac surgery, even after adjustment for

comorbidity and postoperative complications.

Measure Steward




Measure Title

ASA #28: Rate of Post-operative stroke or death in asymptomatic patients

undergoing Carotid Artery Stenting (CAS)

Measure Description

Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the

hospital.

NQS Domain



Outcome

Instructions:

This measure is to be reported each time a CAS is performed during the reporting period. It is anticipated that

clinicians who provide services of CAS, as described in the measure, based on the services provided and the

measure-specific denominator coding will report this measure. This measure may be reported by clinicians who

perform the quality actions described in the measure based on the services provided and the measure-specific

denominator coding..



The listed numerator options are used to report the numerator of the measure. The measure must capture both the

surgical and related anesthesia code. There are no allowable performance exclusions for this measure.

Denominator



AND


AND

(CPT) 01925

AND NOT

Symptomatic carotid stenosis: Ipsilateral carotid territory TIA or stroke less than 120 days prior to

procedure: 9006F

OR

Other carotid stenosis: Ipsilateral TIA or stroke 120 days or greater prior to procedure or any prior

contralateral carotid territory or vertebrobasilar TIA or stroke: 9007F


None



Numerator

Patients who experience stroke or death in the hospital following CAS

Numerator Instructions: A lower calculated performance rate for this measure indicates better

clinical care or control.


Performance Met:

Documentation of patient stroke following CAS (G9257)

OR

Performance Met: Documentation of patient death following CAS (G9256)

OR


Documentation of patient survival and absence of stroke following CAS (G9259)

Rationale

Surgeons performing CAS on asymptomatic patients must select patients at low risk for morbidity and perform

the procedure with a very low complication rate in order to achieve benefit. The proposed measure will therefore

serve as an indicator of both appropriateness and overall outcome.

Clinical Recommendation Statements: Updated Society for Vascular Surgery guidelines for management of

extracranial carotid disease. Ricotta et al, J Vasc Surg, 54:3, 2011

Neurologically asymptomatic patients with ≥ 60% diameter stenosis should be considered for CAS for reduction

of long-term risk of stroke, provided the patient has a 3- to 5-year life expectancy and perioperative stroke/death

rates can be ≤ 3% (GRADE 1, Level of Evidence A).

Measure Steward




Measure Title

ASA #29: Rate of Post-operative stroke or death in asymptomatic patients

undergoing Carotid Artery Endarterectomy (CAE)

Measure Description

Percent of asymptomatic patients undergoing CEA who experience stroke or death following surgery while in the

hospital.

NQS Domain



Outcome

Instructions:

This measure is to be reported each time a CEA is performed during the reporting period. It is anticipated that

clinicians who provide services of CEA, as described in the measure, based on the services provided and the



denominator coding.



The listed numerator options are used to report the numerator of the measure. The measure must capture both the

surgical and related anesthesia code. There are no allowable performance exclusions for this measure.

Denominator



AND


AND

(CPT) 00350

AND NOT

Symptomatic carotid stenosis: Ipsilateral carotid territory TIA or stroke less than 120 days prior to

procedure: 9006F

OR

Other carotid stenosis: Ipsilateral TIA or stroke 120 days or greater prior to procedure or any prior

contralateral carotid territory or vertebrobasilar TIA or stroke: 9007F


None

Numerator

Patients who experience stroke or death in the hospital following CEA

** A lower calculated performance rate for this measure indicates better clinical care or control.**

.




Performance Met: Documentation of patient stroke following CEA (G9258)

OR

Performance Met: Documentation of patient death following CEA (G9260)

OR

Performance Not Met: Documentation of patient survival and absence of stroke following CEA (G9261)

Rationale

Surgeons performing CEA on asymptomatic patients must select patients at low risk for morbidity and perform

the procedure with a very low complication rate in order to achieve benefit. The proposed measure will therefore

serve as an indicator of both appropriateness and overall outcome.

Clinical Recommendation Statements: Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. Ricotta et al,

JVasc Surg, 54:3, 2011

Neurologically asymptomatic patients with ≥ 60% diameter stenosis should be considered for CEA for reduction

of long-term risk of stroke, provided the patient has a 3- to 5-year life expectancy and perioperative stroke/death

rates

can be ≤ 3% (GRADE 1, Level of Evidence A).

Measure Steward




Measure Title

ASA #30: Rate of Endovascular aneurysm repair (EVAR) of small or moderate non-

ruptured abdominal aortic aneurysms (AAA) who expire while in the hospital

Measure Description

Percent of patients undergoing endovascular repair of small or moderate abdominal aortic aneurysms (AAA) that

die while in the hospital.

NQS Domain



Outcome

Instructions:

This measure is to be reported each time an EVAR is performed during the reporting period. It is anticipated that

clinicians who provide services of EVAR, as described in the measure, based on the services provided and the



denominator coding. A lower calculated performance rate for this measure indicates better clinical care or control.


CPT codes, CPT Category II codes and patient demographics are used to identify patients who are included in the

measure's denominator. The measure must capture both the surgical and related anesthesia code. G-codes are used

to report the numerator of the measure.

Denominator



AND

Patient encounter during the reporting period (CPT): 34800, 34802

AND

(CPT): 01926

AND NOT

For women:

Aortic aneurysm 5.5 - 5.9 cm maximum diameter on centerline formatted CT or minor diameter on axial

formatted CT: 9003F

OR

Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on

axial formatted CT: 9004F

OR

For men:

Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on

axial formatted CT: 9004F


None



Numerator

Patients who die in the hospital following endovascular AAA repair

Numerator Instructions: A lower calculated performance rate for this measure indicates better

clinical care or control.


Performance Met:

Documentation of patient death in the hospital following endovascular AAA repair (G9262)

OR


Documentation of patient survival in the hospital following endovascular AAA repair (G9263)

Rationale

Elective repair of a small or moderate sized AAA is a prophylactic procedure and the mortality/morbidity of the

procedure must be contrasted with the risk of rupture over time. Surgeons should select patients for intervention

who have a reasonable life expectancy and who do not have a high surgical risk.

Clinical Recommendation Statements: The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines.

Chaikof et al, J Vasc Surg, 50:4, supplement, 2009.

Elective repair is recommended for patients that present with a fusiform AAA ≥5.5 cm in maximum diameter, in

the absence of significant co-morbidities.

Surveillance is recommended for most patients with a fusiform AAA in the range of 4.0 cm to 5.4 cm in

maximum diameter.

Measure Steward




Measure Title

ASA #31: Total Knee Replacement: Venous thromboembolic and Cardiovascular Risk

Evaluation

Measure Description

Percentage of patients regardless of age or gender undergoing a total knee replacement who are evaluated for the

presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the

procedure (e.g. history of Deep Vein Thrombosis, Pulmonary Embolism, Myocardial Infarction, Arrhythmia and

Stroke).

NQS Domain

Patient Safety


Outcome

Instructions

This measure is to be reported each time a patient undergoes a procedure listed in the denominator during the

measurement period.



The measure must capture both the surgical and related anesthesia code. G-Codes are used to report the numerator

of the measure.

Denominator

Patients regardless of age or gender undergoing a total knee replacement



Patient aged ≥ 18 years on date of encounter

AND


AND


OR


AND


AND


OR




AND


AND


Denominator Exclusions / Exceptions:

None

Numerator

Patients who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors

within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis, Pulmonary Embolism, Myocardial

Infarction, Arrhythmia and Stroke)

Numerator Options:

Performance Met: Patients who are evaluated for venous thromboembolic and

cardiovascular risk factors within 30 days prior to the procedure (e.g.

history of DVT, PE, MI, arrhythmia and stroke) (G9298)

OR

Performance Not Met: Patients who are not evaluated for venous thromboembolic and

cardiovascular risk factors within 30 days prior to the procedure

including (e.g. history of DVT, PE, MI, arrhythmia and stroke, reason

not given) (G9299)

Rationale

Prior to a total knee replacement the patient’s venous thromboembolic and cardiovascular risk should be

evaluated. A population-based study of all Olmstead County, Minnesota, patients undergoing a total hip or knee

arthroplasty from 1994 - 2008, reported that patients undergoing a total knee arthroplasty with a previous history

of a cardiac event or a thromboembolic event were associated with an increased risk of a 90-day cardiac or

thromboembolic event following surgery. (Singh JA, Jensen MR, Harmsen WS, Gabriel SE, Lewallen DG, 2011)

A study using the Danish national resident registries compared all patients undergoing a primary THR and TKR

from 1998 – 2007 to control groups not undergoing one of the procedures and found that the AMI rate 2 weeks

after TKR was increased 31-fold compared to the control group. (Lalmohamed A, Vestergaard P, Klop C, Grove

EL, 2012)

Any preoperative disease state should be identified and managed prior to surgery to minimize the risk of the

surgical procedure.

This measure is designed for use by physicians and eligible health care professionals managing ongoing care for

all patients undergoing a total knee replacement. This measure addresses the preoperative period."

Clinical Recommendation Statements

"ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for the Noncardiac Surgery

(Fleischer LA, Beckman JA, Brown KA, et al. ACC/AHA, 2007)



In patients with known coronary artery disease (CAD) or the new onset of signs or symptoms suggestive of CAD,

baseline cardiac assessment should be performed. In the asymptomatic patient, a more extensive assessment of

history and physical is warranted in those individuals 50 years of age or older, because the evidence related to the

determination of cardiac risk factors and derivation of a Revised Cardiac Risk Index occurred in this population.

Preoperative cardiac evaluation must therefore be carefully tailored to the circumstances that have prompted the

evaluation and to the nature of the surgical illness."

Steward




Measure Title

ASA #32: Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal

Tourniquet

Measure Description

Percentage of patients regardless of age or gender undergoing a total knee replacement who had the prophylactic

antibiotic completely infused prior to the inflation of the proximal tourniquet.

NQS Domain

Patient Safety


Outcome

Instructions

This measure is to be reported each time a patient undergoes a procedure listed in the denominator during the

measurement period.




of the measure.

Denominator

Patients regardless of age or gender undergoing a total knee replacement




AND


AND


OR


AND


AND


OR


AND




AND



None

Numerator

Patients who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet

(tourniquet around the proximal thigh)

Numerator Options:

Performance Met:

Patients who had the prophylactic antibiotic completely infused prior to the inflation of the

proximal tourniquet (G9301)

OR

Medical Performance Exclusion:

Documentation of medical reason(s) for not completely infusing the prophylactic antibiotic prior

to the inflation of the proximal tourniquet (e.g., a tourniquet was not used) (G9300)

OR


Prophylactic antibiotic not completely infused prior to the inflation of the proximal tourniquet,

reason not given (G9302)

Rationale

"The Surgical Care Improvement Project (SCIP) evaluates the timing and appropriateness of the prophylactic

antibiotic. This measure evaluates that the prophylactic antibiotic is completely infused prior to the inflation of the

tourniquet.

This measure is designed for use by physicians and eligible health care professionals managing ongoing care for

all patients undergoing a total knee replacement. This measure addresses the intraoperative period."

Clinical Recommendation Statements

"National Surgical Infection Prevention Project Advisory Statement 2004 (Bratzler DW, Houck PM, 2005)

If a proximal tourniquet is used, the antimicrobial should be completely infused before inflation."

Steward




Measure Title

ASA #33: Unplanned Hospital Readmission within 30 days of Principal Procedure

Measure Description

Percentage of patients aged 18 years or older who had an unplanned hospital readmission within 30 days of

principal procedure

NQS Domain



Outcome

Instructions

This measure is to be reported each time a patient undergoes a procedure listed in the denominator and within the

timeframe of located in the numerator.





control.

Denominator

Patients aged 18 years or older who had an unplanned hospital readmission with 30 days of principal procedure

Denominator Criteria (Eligible Cases): Patients aged 18 years or older who underwent surgical procedures related to: Ventral Hernia, Appendectomy,

AV Fistula, Cholecystectomy, Thyroidectomy, Mastectomy +/- Lymphadenectomy or Sentinel Lymph Node

Biopsy (SLNB), Partial Mastectomy or Breast Biopsy/Lumpectomy +/- Lymphadenectomy or SLNB, Bariatric

Laparoscopic or Open Roux en Y Gastric Bypass, Bariatric Sleeve Gastrectomy, Colectomy and who had an

unplanned hospital readmission within 30 days of principal procedure.



AND


60252, 60254, 60260, 60271

AND


OR


AND

Patient encounter during the reporting period (CPT): 19101, 19301, 19303, 19304

AND




OR


AND


AND


OR


AND


AND


OR


AND


AND


OR


AND


AND


OR


AND


49656, 49657

AND


OR


AND


44147, 44204, 44206, 44207, 44208, 44960, 49561, 49566

AND

Patient encounter during the reporting period (CPT): 00790 OR 00840



OR


AND


47563, 47564, 47600, 47605, 47610

AND


OR


AND

Patient encounter during the reporting period (CPT): 43644, 43645, 43775, 43846, 43847

AND


OR


AND


AND


OR


AND


AND


OR


AND


AND


OR


AND

Patient encounter during the reporting period (CPT): 36818, 36819, 36820, 36821, 36825, 36830

AND





None

Numerator

Patients aged 18 years or older who had an unplanned hospital readmission within 30 days of principal procedure

to the same hospital or an outside hospital for any reason

Note: A lower calculated performance rate for this measure indicates better clinical care or control

Numerator Quality-Data Coding Options for Reporting Satisfactorily Performance Met: Unplanned hospital readmission within 30 days of principal procedure

(G9310)

OR

Performance Not Met: NO unplanned hospital readmission within 30 days of principal procedure

(G9309)

Rationale

This is an adverse surgical outcome, which is often a preventable cause of harm, thus it is important to measure

and report. The measure allows measurement across the person-centered episode of care out to 30 days after the

procedure whether an inpatient, outpatient, or readmitted.

Steward


.



Measure Title

ASA #34: Surgical Site Infection

Measure Description

Percentage of patients aged 18 years or older who had a surgical site infection (SSI)

NQS Domain



Outcome

Instructions

This measure is to be reported each time a patient undergoes a procedure listed in the denominator and within the

timeframe identified in the numerator.





control.

Denominator

Patients aged 18 years or older who underwent surgical procedures related to: Ventral Hernia, Appendectomy,



Laparoscopic or Open Roux en Y Gastric Bypass, Bariatric Sleeve Gastrectomy, Colectomy and who had a

surgical site infection (SSI).

Denominator Criteria (Eligible Cases): Patients aged 18 years or older who underwent surgical procedures related to: Ventral Hernia, Appendectomy,



Laparoscopic or Open Roux en Y Gastric Bypass, Bariatric Sleeve Gastrectomy, Colectomy and who had a

surgical site infection (SSI).



AND


60252, 60254, 60260, 60271

AND


OR


AND

Patient encounter during the reporting period (CPT): 19101, 19301, 19303, 19304

AND




OR


AND


AND


OR


AND


AND


OR


AND


AND


OR


AND


AND


OR


AND


49656, 49657

AND


OR


AND


44147, 44204, 44206, 44207, 44208, 44960, 49561, 49566

AND



Patient encounter during the reporting period (CPT): 00790 OR 00840

OR


AND


47563, 47564, 47600, 47605, 47610

AND


OR


AND

Patient encounter during the reporting period (CPT): 43644, 43645, 43775, 43846, 43847

AND


OR


AND


AND


OR


AND


AND


OR


AND


AND


OR


AND

Patient encounter during the reporting period (CPT): 36818, 36819, 36820, 36821, 36825, 36830

AND





None

Numerator

Percentage of patients aged 18 years and older who had a surgical site infection (SSI)

Note: A lower calculated performance rate for this measure indicates better clinical care or control

Definition:

Superficial Incisional SSI: Superficial incisional SSI is an infection that occurs within 30 days after the

operation and infection involves only skin or subcutaneous tissue of the incision and at least one of the

following:

Purulent drainage, with or without laboratory confirmation, from the superficial incision

Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial

incision

At least one of the following signs or symptoms of infection: pain or tenderness, localized

swelling, redness, or heat AND superficial incision is deliberately opened by the surgeon, unless

incision is culture-negative

Diagnosis of superficial incisional SSI by the surgeon or attending physician

Deep Incisional SSI: Deep Incision SSI is an infection that occurs within 30 days after the operation and

the infection appears to be related to the operation and infection involved deep soft tissues (for example,

fascial and muscle layers) of the incision and at least one of the following:

Purulent drainage from the deep incision but not from the organ/space component of the surgical

site

A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient

has at least one of the following signs or symptoms: fever (> 38 C), localized pain, or tenderness,

unless site is culture-negative

An abscess or other evidence of infection involving the deep incision is found on direct

examination, during re-operation, or by histopathologic or radiologic examination

Diagnosis of a deep incision SSI by a surgeon or attending physician

Organ/Space SSI: Organ/Space SSI is an infection that occurs within 30 days after the operation and the

infection appears to be related to the operation and the infection involves any part of the anatomy (for

example, organs or spaces), other than the incision, which was opened or manipulated during an operation

and at least one of the following:

Purulent drainage from a drain that is placed through a stab wound into the organ/space.

Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space

An abscess or other evidence of infection involving the organ/space that is found on direct

examination, during re-operation, or by histopathologic or radiologic examination

Diagnosis of an organ/space SSI by a surgeon or attending physician

Numerator Quality-Data Coding Options for Reporting Satisfactorily Performance Met: Surgical site infection (G9312)

OR

Performance Not Met: NO surgical site infection (G9311)

Rationale



This is an adverse surgical outcome, which is often a preventable cause of harm, thus it is important to measure

and report. The measure allows measurement across the person-centered episode of care out to 30 days after the

procedure whether an inpatient, outpatient, or readmitted.

Steward



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